A nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse expect?
The infant has a pincer grasp.
The infant drops objects with the expectation of someone picking them up.
The infant makes babbling sounds.
The infant crawls on their hands and knees.
The Correct Answer is C
Choice C reason: The infant makes babbling sounds. At 6 months of age, it is typical for infants to engage in babbling sounds. Babbling is a significant milestone in language development during infancy. It involves the repetition of consonant-vowel combinations (e.g., "ba-ba,”. "ma-ma") and is an essential precursor to later language skills, such as forming words and sentences. The nurse should expect the 6-month-old infant to be making these babbling sounds as part of their normal development.
Choice A reason:
The infant has a pincer grasp. A pincer grasp is the ability to pick up small objects using the thumb and index finger. This fine motor skill typically develops around 9 to 12 months of age. At 6 months old, infants have not yet acquired the pincer grasp. Therefore, the nurse should not expect the 6-month-old infant to demonstrate this skill during the assessment.
Choice D reason:
The infant crawls on their hands and knees. Crawling is a gross motor skill that usually emerges between 7 to 10 months of age. While some infants may start crawling earlier or later, it is not a skill that is typically present in a 6-month-old. Therefore, the nurse should not anticipate the 6-month-old infant to be crawling on their hands and knees during the assessment.
Choice B reason:
The infant drops objects with the expectation of someone picking them up. This behavior, known as "object permanence,”. is a cognitive milestone that develops around 8 to 12 months of age. At 6 months old, infants have not yet fully developed this concept. They might drop objects as part of their exploratory behavior, but they do not yet understand the expectation of someone picking them up. Therefore, the nurse should not expect the 6- month-old infant to exhibit this specific behavior during the assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.
Choice A reason:
The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.
Choice C reason:
The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.
Choice D reason:
Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.
Correct Answer is A
Explanation
Choice A reason:
The nurse's priority in this situation is the respiratory rate of 10/min. A respiratory rate of 10 breaths per minute is significantly low and could indicate respiratory depression, especially if the patient is receiving morphine, which is known to depress the respiratory system. This could lead to inadequate oxygenation, potential hypoxia, and other life-threatening complications.
Choice B reason:
Bladder distention may be a concern, but it is not the nurse's priority in this situation. Bladder distention can cause discomfort and urinary retention, but it is not an immediate life- threatening condition compared to potential respiratory depression.
Choice C reason:
A blood pressure of 108/64 mm Hg is within the normal range for an adolescent and may not be the nurse's priority at this time. Although it should be monitored, it does not pose an immediate threat to the patient's life.
Choice D reason:
Nausea and vomiting are common side effects of morphine administration, but they are not the nurse's priority in this situation. While they can cause distress and discomfort to the patient, they are not life-threatening conditions.
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